Section: Claims Payment - Cognitive Services (PAS Policy Administered by Drug Plan and Extended Benefits Branch) Reference Date of Issue June 3, 2009 Approved by Director of Operations PACT Partnership to Assist with Cessation of Tobacco POLICY: Effective January 18, 2009, the Drug Plan and Extended Benefits Branch (DPEBB) will pay pharmacists $2.00/minute to a maximum of $300.00 per patient per year to provide tobacco cessation support and services as well as ten follow-up sessions. PURPOSE: To achieve significant, realistic reductions in disease and death due to tobacco use by reducing tobacco use prevalence among Saskatchewan residents. As tobacco users successfully quit there will be a residual decrease in exposure to second hand smoke to others as well. To aid in the identification of tobacco users and the offering of cessation support within a pharmacist s practice. To provide pharmacists with compensation for cognitive services in tobacco cessation support. Develop partnerships between tobacco users, pharmacists, prescribers and other health professionals to support successful cessation attempts. ELIGIBLE CLIENTS/PRESCRIPTIONS: Client must be a beneficiary under the DPEBB. A beneficiary is a Saskatchewan resident with an active Health Services Number, and not covered under Workers Compensation, SGI, Non- Insured Health Benefits, Veterans Affairs, RCMP, or Armed Forces Clients are allowed PACT counselling once per year only. PROCEDURE: The Drug Plan will: o Remunerate the PACT fee to the pharmacy upon submission of an electronic claim. o Process Pharmacy Paper Claims for PACT services submitted more than 62 days from the date of service and prior to the availability of on-line billing. The Pharmacists Association of Saskatchewan will: o Set the policy for the PACT program. o Inform pharmacies about PACT program billing processes. o Clarify PACT policy with pharmacies. o Notify pharmacies of any changes to the PACT program. o Audit PACT billings from pharmacies. The Pharmacy will: o Follow billing procedures outlined in this document. o Document patient information and pharmacist time using Form 3G in the PACT binder. o Ensure appropriate documentation is available upon request by PAS for verification for a minimum of three years. o Submit claims to the Drug Plan based on Table 1. 1
Table 1: Billing Procedure for PACT Claims 1. Submit an electronic claim* for PACT counselling: The Drug Plan will pay 100% of the PACT fee to the pharmacy, all funds being paid from the Alternative Reimbursement Fund. *submit a Pharmacy paper claim for PACT services provided more than 62 days from the date of service and prior to the availability of on-line billing. 2. Enter the following fields on the Drug Plan WEB page: Pharmacy Number: Enter your three-digit pharmacy code (ie: 123) Patient Identifier: Enter the nine-digit Health Services Number (HSN) Dispensing Date (DD/MM/CCYY): Enter the PACT counselling date Rx Number: Enter the RX number preceded with an A (ie: A123456) Health Provider Organization ID: Emter SKCP Health Provider ID: Enter the pharmacist license number (ie: D1234) Pharmacist Organization ID: Enter SK Pharmacist ID: Enter the pharmacist license number (ie: D1234) DIN: Enter the DIN for the Stage of service Stage PseudoDIN Comment Bronze 00990051 Maximum 1 submission at $5.00 (2.5 minutes) Bronze Plus 00990052 Maximum of 1 submission at $10.00 (5 minutes) Silver/Gold 00990053 Maximum of 3 submissions totalling 90 minutes for a maximum of $180.00 Follow-up 00990054 Maximum of 10 submissions x $10.00/submission for a total of $100.00 (50 minutes). Compound Fee: Enter 0.00 Compound Name: Leave blank Methadone per day: Leave blank No Sub: Click on no Quantity: Enter the two-digit code as below: Stage Code Bronze 51 Bronze Plus 52 Silver/Gold 53 Follow-up 54 Days Supply: Enter 1 Unit Price: Enter Total Time of the session x $2.00 per minute (ie: if 5 min session, enter 10.00) Dispensing Fee: $0.00 Markup Enter 0,0,0 for Percent 1, 2, 3 Discount Percentage: Enter Total Prescription Cost: Total dollar value billed (Actual time in minutes x $2.00) Patient Paid Amount: $0.00 Adjudication flag: Click on Yes RESERVED FOR FUTURE USE: Defaults to No Third Party Insurance Flag: Defaults to No If you are unable to bill the PACT fee electronically through your Practice Management System, you MUST use the WEB page https://www.drugplan.health.gov.sk.ca. If you are unsure how to install the WEB certificate, please contact your software vendor. To use the Web page, refer to the DPEBB Pharmacy Reference Manual, Section VI. Contact PAS at 306-359-7277 to clarify policy. 2
APPENDIX A: CRITERIA A) Bronze: Identification of Tobacco Users in Practice Site/ Assessing Stage of Change - Maximum of 2.5 minutes to engage tobacco user in discussion about tobacco use and stage of change, referral to PACT trained pharmacist www.skpharmacists.ca, and/or Smokers Helpline 1-877-513-5333 www.smokershelpline.ca. - Three questions: o Do you use tobacco? OR Are there any tobacco users in your home? o Are you willing to briefly discuss your smoking/tobacco use? o What do you think about quitting tobacco? - Document Stage of Change using Appendix B and Patient Profile/PIP (for non-pact pharmacist) - Document using 3 G Log and Patient Profile/PIP ( for PACT trained pharmacist) - Process Claim using Pseudo-DIN 00990051 - Bronze Services Maximum billable amount is $5.00 Precontemplation -Not thinking of quitting -Defensive/Not receptive to information -Pros<Cons Contemplation -Thinking of quitting in 6 months -May be receptive to input -Pros=Cons Preparation -Has made decision to quit in 1-2 months -Receptive to assistance -Pros>Cons Action -Quitting now or in a few days -Develops tobacco-free action plan & strategies to deal with triggers, and relapse Maintenance -Has quit for 6 months -Dealing with triggers, cravings & slips -Requires ongoing encouragement -May lead to Termination Stage (no longer tempted to use tobacco) All pharmacists can provide and bill for Bronze Level Services. It is recommended that non-pact pharmacists refer tobacco users to PACT pharmacists especially if it is determined that the tobacco user is in preparation or action stage. Only PACT trained pharmacists can provide and bill for Bronze Plus, Silver, Gold Level Services and Follow-up B) Bronze Plus: Identification of Tobacco Users in Practice Site/ Assessing Stage of Change/ Conviction and Confidence Scores -Maximum of 5 minutes to engage tobacco user in discussion about tobacco use, stage of change and level of conviction and confidence. If in Contemplation, Preparation or Action stage, and willing to enrol in the PACT program, provide with PACT service promotional materials and other information. Questions: Do you use tobacco? OR Are there any tobacco users in your home? Are you willing to briefly discuss your smoking/tobacco use? 3
What do you think about quitting tobacco? (Assess Stage of Change as in Bronze ) Conviction: If you decided to quit, how would you benefit? -reformulate,reinforce & refocus the answer -ask to elaborate on personal reasons for quitting Confidence: If you really decided to quit tobacco, do you think you could do it? What would prevent you from quitting? How do you think you can overcome this barrier? Low Conviction = Precontemplation Medium Conviction = Contemplation High Conviction = Preparation High Conviction and Confidence - Action Increase Conviction & then boost Confidence - Document time, Stage of Change, & Conviction and Confidence scores using 3 G Log - Process Claim using Pseudo-DIN 00990052 - Bronze Plus Services Maximum billable amount is $10.00 C) Silver: Tobacco User Previously Indicates Quitting Tobacco within 6 months -Collect patient s tobacco history, personal risk factors and motivations or barriers to cessation, assess tobacco users stage of change, triggers for smoking, health beliefs, pharmacotherapy recommendation, and contact physician if necessary (estimated time:30 to 60 minutes). Tobacco users already in action stage may not need silver level intervention and may be able to go right to gold level. -Process Claim using Pseudo-DIN 00990053 (see below for details) D) Gold: Tobacco User is Ready to Quit -Confirm QUIT date, review risks of tobacco use, motivation, and benefits of quitting, discuss strategies to handle slips or relapses, pharmacotherapy recommendations, contact with physician if necessary (estimated time: 30 to 60 minutes ) and arrange follow-up by phone or in person -Process Claim using Pseudo-DIN 00990053 -Silver Level Services & Gold Level Services are billed using the same pseudo-din Maximum billable amount is $180.00 (90 minutes) billable in three appointments. For example, a tobacco user in preparation stage may require one appointment of 45 minutes in Silver and a second appointment of 30 minutes in Gold, which would be billable as follows: 45 minutes (00990053) x $2.00/min = $90.00 30 minutes (00990053) x $2.00/min = $60.00 Another tobacco user may require three appointments two in Silver and one in Gold each 30 minutes in length. This would be billable as follows: 30 minutes (00990053) x $2.00/min = $60.00 (Silver) 30 minutes (00990053) x $2.00/min = $60.00 (Silver) 30 minutes (00990053) x $2.00/min = $60.00 (Gold) This would be the maximum number of claims that could be processed(3) and the maximum dollar amount paid for Silver/Gold Level Services ($180.00). 4
In the previous example services are billed only twice for a total of $150.00 The total minutes and number of claims can occur in any combination as long as they do not exceed $180.00 total (90 minutes) in three sessions. E) Proposed Follow-ups Quit Day, Day 3, Day 7, Day 14 to 21, Day 30, Day 60, Day 90, Day 120, Day 180 to 240 & Day 300 to 365 -Determination of smoking status, ensuring adherence with/tolerance of pharmacotherapy -Discuss triggers, cravings, withdrawal, slips & relapses, coping strategies, & quit tips and tricks -Problem solving -Behavior modification strategies -Follow-up will consist of phone call, in-person discussion or email contact. -Estimated time per contact is 5 minutes. -Process Claim using Pseudo-DIN 00990054 -Follow-up Services Maximum billable amount is $100.00 which includes 10 follow-ups billable at $10.00 each. It is recommended that the majority of follow-up occurs at the beginning of cessation when the patient is most likely to slip or relapse. F) Group Sessions: - Silver and Gold Level Services are provided in a group setting for more than one patient at a time. - Pseudo- DIN used is 00990053 to a maximum of $150.00/patient ($1.00/minute to a maximum of 150 minutes) per year. - Billing of Follow-up is allowed at the same maximum of $100.00 for 10 follow-up appointments using pseudo-din 00990054. 5